Brun Lea Care

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question Good. At this assessment the rating has changed to Requires Improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation as risks to people's health, safety and welfare were not consistently assessed, monitored or mitigated. Concerns were identified in relation to care planning, risk assessments, pressure area care, moving and handling, nutrition and hydration, and medicines management, resulting in insufficient assurance that people were receiving safe care and treatment. As a result, people were not always protected from the risks associated with unsafe or inappropriate care and treatment.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

The provider had recognised a number of areas requiring improvement and had sought external support to strengthen governance, medicines management and quality assurance processes. However, opportunities to learn from incidents and concerns had not always been fully embedded. Records showed medication incidents and concerns had not always been clearly documented, investigated or used to drive improvement. For example, a medication-related concern was not investigated promptly, as a lack of adherence to established procedures meant managers were unable to determine where the error had occurred.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

Systems were not always effective in ensuring information remained accurate when people's needs changed. Care records contained examples of conflicting information and care plans that did not reflect current care needs. Medication changes following hospital discharge had not always been transferred onto medicines administration records, increasing the risk of inconsistent care.

The provider had identified weaknesses within its admission processes and had begun reviewing pre-admission assessments to ensure information received from external professionals was verified before admission.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

People told us they felt safe at the home. One person said, “I feel safe, [staff] come and see if you are alright in bed and someone comes around in the night.”

Staff demonstrated an understanding of safeguarding processes and were able to describe different forms of abuse and how concerns should be reported. Staff told inspectors they would raise concerns with management and escalate concerns externally if appropriate action was not taken.

However, we identified multiple concerns relating to risk management, medicines management, care planning, recruitment processes, decision-making and oversight. These concerns had not always been recognised, escalated or addressed in a timely way. As a result, although staff were able to describe safeguarding procedures, inspectors could not be fully assured that staff consistently recognised when poor practice, neglect or unsafe care may place people at risk of harm.

Records reviewed showed that Deprivation of Liberty Safeguards(DoLS) authorisations were in place for some people and staff demonstrated a basic understanding of their responsibilities under the Mental Capacity Act and DoLS. However, oversight of DoLS was not always effective. One authorisation had expired and was awaiting renewal. This reduced assurance that restrictions placed upon people were consistently supported by up-to-date legal authorisations.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Care plans did not consistently provide staff with sufficient guidance to support safe and consistent care. Records reviewed were incomplete, out of date or contained conflicting information. For example, one person's moving and handling care plan was not reflective of their current needs and did not correspond with observed practice.

People identified as being at very high risk of pressure damage did not always have appropriate preventative interventions or clearly documented rationales for decisions regarding pressure-relieving equipment. One person assessed as being at very high risk of pressure damage was using a standard mattress despite the identified risk.

Risks associated with nutrition, hydration and swallowing were not always appropriately managed. One person had experienced significant weight loss without evidence of documented action being taken in a timely manner. Another person who required full assistance with eating and drinking did not have clear guidance regarding positioning during meals or specialist swallowing assessment information recorded within the care plan.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

During the inspection, an internal kitchen door and rear external door were observed unlocked while no staff were present in the area. This increased the risk of people accessing areas that may present hazards and of people leaving the service unnoticed, particularly those living with cognitive impairments or who may be unable to recognise risks.

On the first day of the inspection, a hoist was unavailable for use because it had not received the required servicing. This meant some people were unable to get out of bed and access communal areas or participate in their usual activities. The provider took action to address this, and the hoist had been serviced and returned to use by the second day of the inspection.

Medicines storage arrangements required improvement. Concerns were identified regarding medicine room temperatures, monitoring systems and medication fridge security. Inspectors also identified the controlled drugs cupboard required securing in accordance with safe storage requirements.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. The provider had not always followed safe recruitment processes.

People told us there were enough staff to meet their needs. A person said, “There are enough staff, we have a laugh and a joke… I get on well with most of them.”

Recruitment files reviewed contained missing information, including incomplete employment histories, outstanding references and gaps in pre-employment checks. One member of staff, whose essential recruitment checks remained incomplete, was working independently, had access to medication keys and was administering medicines. This exposed people to the risk of receiving care and support from staff whose suitability for the role had not been fully verified.

Systems for monitoring staff supervision and competency were not sufficiently robust. There were gaps in oversight arrangements and staff had not received regular supervision to support safe working. Medicines competency assessments had been completed for all staff who administered medicines

There were enough staff to meet people’s needs. Staff described receiving induction training covering topics such as safeguarding, infection prevention and control, moving and handling, medication and MCA/DoLS. Staff also reported feeling supported by managers and able to raise concerns.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff demonstrated a good understanding of infection prevention and control procedures. They described the use of personal protective equipment, waste segregation, laundry processes and cleaning arrangements. Cleaning schedules, deep cleaning processes, monthly mattress checks and water temperature monitoring systems were in place.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

People told us they were happy with the way their medicines were managed and received them on time. However, we identified significant concerns with medicines safety.

Medicines administration records were incomplete and did not consistently contain all required information. Some records lacked staff signature information, administration preferences or complete resident profiles. PRN protocols were not available despite people receiving medicines prescribed on an "as required" basis. Some medicines prescribed for occasional use were being administered routinely without evidence of review.

Where people may have been unable to verbally communicate pain, there was no evidence of pain assessment tools or supporting guidance being used.

Arrangements for covert medication administration were incomplete. While some documentation was present, records did not consistently demonstrate pharmacy involvement or provide clear instructions for administering individual medicines covertly.

Records relating to topical medicines and transdermal patches lacked sufficient information, including application sites, body maps and patch removal records. There were inaccuracies in controlled drugs records where returned medication remained documented as being in stock.

The provider had recognised medicines management as a risk area and had implemented additional audits, changed pharmacy support arrangements and introduced further staff training. However, improvements had not yet resulted in consistently safe practice.